Group Producers Corner Registration




Section I


Prefix:	Suffix:

First Name:	Middle Initial:	Last Name:

Address Line One:	Address Line Two:

City:	State / Territory:	Zip / Postal Code:

E-Mail Address:	SSN:	Mother's Maiden Name:

Commission E-Mail Address: Auto Fill E-Mail Address Above	Agent Number: Auto Fill SSN Above


Phone Number: --Ext.	Alternate Phone Number: --Ext.	Fax Number: --



Section II - Agent / Broker Identification

I:	Broker Agency Name:


I:


Licensed in:	« Add Remove »	State / Territory:

Comments: 450 characters remaining

Section III - Agreement

Usage and Security Information:
Any information submitted via this registration form is intended solely for use by Dearborn Life Insurance Company. For security purposes, your information will be encrypted during its transmission to prevent unauthorized third-party access.

Terms of Registration:

Terms of Use and Privacy Statement

Terms of Use
Please read the following information in its entirety since it represents a binding agreement between you and Dearborn Life Insurance Company.
While using this website, you agree that you will not use any device or computer program in order to interfere or attempt to interfere with the proper operation of this website (e.g., hacking, denial of service attacks). This includes any activity that precedes attempts to breach security such as scanning, probing, or other testing or vulnerability assessment activity, or engaging in or permitting any network or hosting activity that results in the blacklisting or other blockage of our IP space. You also agree not to copy, reprint, modify, lease, distribute, assign, sell content, license, reverse engineer or create derivative works retrieved from this website or any of the third-party websites we may provide links to, or use this website in a manner that may adversely affect this website's resources or its availability to others, or that violates U.S., local, state or federal law.

Online Security
When you are submitting or transferring data via this website, it is protected by Transport Layer Security (TLS) technology, the leading security protocol for data transfer on the Internet. Even though there are many benefits to using this website, as with all electronic communications there are some risks which may include: the failure of hardware, software and/or Internet connections; we are not responsible for failures, distortions, delays, or other problems resulting from equipment configuration, connection, signal power, hardware, software or any equipment used to access the Internet. There is no guarantee that the confidentiality or security of electronic transmissions via the Internet can be assured due to potentially unsecure computers and links. This could result in your data becoming lost or intercepted during transmission. Please use good judgment before deciding to send information via the Internet.

Third-Party Links
The website may offer you links to other websites, pages or iframes hosted by independent third parties. At times, Dearborn Life works with such third parties to create the content on these websites; at other times, a link to these websites is provided solely as a resource or convenience for our users. Since these third-party websites are not hosted or maintained by Dearborn Life, we do not make any guarantees or warranties as to the validity or accuracy of the information posted on these websites, or for any products or services that may be available on these websites. As a result, you agree that Dearborn Life has no liability for any damages you may incur as a result of your use of or the information you receive from or submit to these third-party websites. The use of these third-party websites may subject the user to separate binding agreements, including terms of use and privacy statements, which can be found on the third-party website if applicable. Be sure to read these additional agreements and statements and have a working understanding of the terms.

Privacy Statement
We know how important the security and privacy of data is to you. Therefore, please review the following statement which explains what data we collect, how we use the personal information you provide, and how we keep that information secure. "Personal Information" refers to data that is unique to you such as name, birth date, address, email address, IP address and telephone number. If you encounter a screen or page that requests information you do not want to share with us, do not enter the information and do not proceed with that screen or page.

Information Collected and Used
For purposes of this site, we may collect and use your email or phone/text number that you provide in order to respond to your inquiry or to send you information about a service or resource that you expressed interest in. We will continue to send you information unless you request us to stop or opt out. In addition, we may receive information from the third-party sites that you access through the site.
You may also decide to use your email or text number to ask us questions and provide comments about our website or services. You are encouraged to provide this feedback. We do share these messages with individuals in the organization who can appropriately respond; we may preserve the content of your message along with our response. At times, we may use a third-party vendor to determine if you open and use any information that we share via email, as well as to solicit your feedback through online surveys. Responding to these surveys is optional.
In addition, to the information listed above, we also collect electronic data about you in order to provide a positive website experience, offer health care programs, products and services and report on user activity. The tools we use are listed below. Please be aware that none of these tools provide Dearborn Life with the ability to read any data residing on your computer.
Cookies and tags are used on websites to gather information about how individuals use and navigate the website. Neither cookies nor tags can extract any personal information about you, nor can they read any data that resides on your personal computer or device. The data collected from these sources are used to recognize repeat users and track usage patterns. Specifically, we use "cookies," which are small pieces of information sent by a web server and stored by a member's web browser. Cookies allow the web server to maintain an active "session" with an individual user and track what users are accessing on the site.
We may use the information collected from the cookies and tags for tracking resources and data accessed on the site, recording general site statistics and activity, troubleshooting website problems and tracking what tools users are accessing on the site. This information may be combined with other information that we may have about you for data analytics, marketing and reporting, but only as permitted by law.

Miscellaneous

Governing Law
These Terms of Use and your use of our website are governed exclusively by the laws of the State of Illinois, without reference to its rules regarding choice of law.

Limitation of Liability
You agree that you use this website at your own risk. Dearborn Life Insurance Company and its licensors have no liability for any damages (whether direct or indirect, special, incidental, consequential or punitive) incurred by you as a result of your use of this website or the information you receive from or submit to this website. Dearborn Life and its licensors shall have no liability whatsoever for failure of electronic or mechanical equipment or communication, telephone or other connection problems, computer viruses, unauthorized access or interception of data from this website, theft or errors.

Ownership and Copyright Protection
All right, title and interest in the content (including software, text and images) and other intellectual property (including trademarks, service marks and copyrights) on this website are solely and exclusively the property of Dearborn Life or its licensors and are protected by intellectual property laws. You acknowledge that content available through the website, including, without limitation, content of third parties is protected by copyright, trademark, patent or other intellectual proprietary rights and laws.

Changes to the Terms of Use and Privacy Statement
Evolving technology will require us to update or amend our Terms of Use and Privacy Statement from time-to-time; the version date located at the bottom of this page will reflect the last time that they were updated.

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